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Special Test

Windlass Test | Plantar Fasciitis Examination

Windlass Test is used for plantar fasciitis examination, a “windlass” meaning is the tightening of a rope or cable. The plantar fascia is like a cable attached to the calcaneus and the metatarsophalangeal joints. 

The windlass mechanism principle is characterized by the shortening of the plantar fascia, which effectively reduces the distance between the calcaneus and the metatarsals, thereby facilitating the elevation of the medial longitudinal arch. This shortening of the plantar fascia is principally induced by dorsiflexion of the hallux.

How do perform the Windlass Test?

There are two methods to perform the Windlass test during plantar fasciitis examination:

In the first version: the patient’s knee was flexed to 90 degrees while in a non−weightbearing position. The examiner stabilized the ankle and extended the MTP joint while allowing the IP joint to flex, thus preventing motion limitations due to a shortened hallucis longus muscle.

In the second method: the patient was standing on a step stool with toes over the stool’s edge. Again the MTP joint was extended while the IP joint was allowed to flex.

See Also: Foot Anatomy

What does a positive Windlass Test mean?

The Windlass test is positive if the heel pain is reproduced with passive dorsiflexion of the MTP joint indicating that the plantar fascia is tight and may be contributing to the plantar fasciitis.

See Also: Ankle Examination

Accuracy

A study on 22 patients with plantar fasciitis, 23 patients with other types of foot pain, and 30 controls, the Reliability for this test was:

  • Intraexaminer: ICC = 99%
  • Interexaminer: ICC = 96%

Seven of the 22 patients in the plantar fasciitis group had a positive weightbearing Windlass test (31.8%), while only three had a positive test result in a non-weightbearing position (13.6%). 

This study conclude that despite its high rate of specificity, the low rate of sensitivity of the Windlass test may limit its usefulness in the clinical evaluation in patients with plantar fasciitis.

windlass test mechanism

Windlass Effect

Maximally dorsiflexing the great toe tenses the plantar fascia and also recreates the medial longitudinal arch in a patient with a mobile pes planus deformity, the so-called ‘windlass effect’.

windlass effect
The ‘windlass effect’. The great toe is maximally dorsiflexed, which tightens the plantar fascia and helps to reform the medial arch

Another way to show the windlass effect is by asking the patient to rise up on tiptoe. This maneuver is also called a heel raise. This maneuver normally produces an involuntary inversion of the heel and an accentuation of the medial longitudinal arch. Absence of the normal windlass effect may be secondary to stiffness owing to arthritis, a tarsal coalition, or injury lo the posterior tibial tendon or spring ligament.

rise up on tiptoe
Rise up on tiptoe

Notes

Imaging studies can also be used to diagnose plantar fasciitis. X-rays can be used to evaluate the structure of the foot and rule out any other underlying conditions, such as stress fractures or bone spurs. Magnetic resonance imaging (MRI) can be used to assess the soft tissue structures of the foot, including the plantar fascia, to evaluate for any damage or inflammation.

In some cases, diagnostic injections may be used to help diagnose plantar fasciitis. A local anesthetic can be injected into the plantar fascia to see if it provides pain relief, which would indicate that the plantar fascia is the source of the patient’s pain. A corticosteroid injection can also be used to reduce inflammation in the plantar fascia, although this should be reserved for patients who have failed conservative treatment options.

The plantar fascia contributes more mechanical support to the arch than the spring ligament, plantar ligaments, or intrinsic muscles.

References

  1. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2003 Mar;24(3):251-5. doi: 10.1177/107110070302400309. PMID: 12793489.
  2. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.
  3. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004 Jan;39(1):77-82. PMID: 16558682; PMCID: PMC385265.
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